A question for NHS staff

[Glowinginthedark]

AIBU to think that no amount of money throw at the NHS in it current state will fix the issues? What is the real problem? Lack of funds or people completely abusing and misusing A&E or both?

Loobyloo - I think long term that's absolutely right. but until someone sorts it all out, the money will just get sucked into a black hole

As I said upthread, I don't really use the NHS but I'd happily pay a bit more tax dedicated to it if I thought the money would go on the right things.

I think it’s gone beyond repair rely which is so so sad

Msqueen33: "I do think some things such as drunks and alcohol related things that clog up A&E deserve to pay for it." dangerous road to go down. People with alcohol addiction issues are sick, mentally unwell. They deserve care like the rest of us who break our legs doing sports or have self harm wounds from depression. And the people who end up there through accidents while drunk, where do you draw the line? Breathalyse everyone and if you are over the drive limit you don't get treated if you can't afford it? What about when you meet friends for a couple glasses of wine and cockle over on your ankle and break it? It's not as black and white as people make out. I don't want to see an NHS where we don't treat smokers with lung cancer or overweight people with knee issues or people with a broken limb from sports. I agree people need to take more responsibility for themselves however, I'm as guilty of this as anyone at times!

But the problem with advanced directives is simply this.

An individual; may want them to use all pro active measures on them to keep them alive as long as possible. As may the family. So there might be no advance directive and when asked, the NOK might well say, please keep intervening.

However I think there needs to be a point where the NHS says No. It is not worth occupying a critical care bed and spending £XXXX on this patient who will die anyway. We won't be saving their life we'll merely be delaying death.

What is best for the individual might not be best for society. So long as the decisions are made in the balance, then I don't see any harm with this.

an advance directive allows a person to specify do not resuscitate and other decisions such as no antibiotics if I get pneumonia and my diagnosis is only a few months to live.

Not ideal, though, is it? If I get dementia, it's not going to be much use to me - even the pneumonia get-out won't help because it will be argued that they'll have to vaccinate me to protect others in the home.

@woolythoughts some very valid points in your post there. I know nothing of neonatal / paediatrics but am very experienced caring for the elderly and sadly, the point you raise resonates.

Case example - one resident had a fall. They had advanced dementia, severe arthritis as well as a whole host of other complex healthcare issues. This person was 94. They had sensor mats, all the appropriate risk assessments etc but they just got up from their chair and dropped down.

Result? A broken hip. Rushed into A & E, given a same day op to repair the fracture. Returned to us 3 days later, very worse for wear, and stopped eating / drinking etc. Basically they died 2 weeks post-op.

I don't know what the alternative was other than the op as no one would have wanted this person to be in pain - but was the cost of the initial treatment, scans, the op itself, pain relief and then daily fragmin injections from a district nurse really the best course as they died so soon after?

Even the GP I called to asses them following discharge said to me that this happens time and again. Broken hip - the NHS fixes it but the trauma is too great so they end up passing away within, at the latest, 6 months anyway. But what is the answer or the alternative?

Personally I have made the decision to have a DNR put in place once I hit 75 whether I have a long term health condition on not as god knows what care will be available to me at that age anyway and I don't want others missing out on treatment that would benefit them but not me IYSWIM? My mother feels the same. She is also an ex NHS and care home worker.

The whole thing is a mess.

321 I know what an advanced directive is. It's not the same as someone who is wasting away with, say, MND, who wants to go before the illness gets beyond a certain point. Or someone with conditions who are paralysed and can't take their own life and have been to the courts to get permission and were refused (been a couple of high profile cases).

@Stewpots

The answer might be to provide pain management, normal food and water but withdraw medical treatment for anything else. Let nature take its course.

Shatners No it's not the same. Don't want to derail thread but IMO the slippery slope argument carries more weight. Baroness Campbell makes a compelling read.

"Wooly* "However I think there needs to be a point where the NHS says No. It is not worth occupying a critical care bed and spending £XXXX on this patient who will die anyway. We won't be saving their life we'll merely be delaying death." This happens anyway. As an example Liverpool Pathway implementation.

So why wasn't it used in the case of the 94 year old dementia patient who go a useless hip replacement?

@woolythoughts exactly. But as you say emotion stops sensible decisions being made. Thank god my mum has already gone through her wishes with me.

She has no long term health conditions and at 72 is in good physical and mental health. Takes no medication, good diet, exercise etc. Probably healthier than I am!

But she has stated that when it comes to the time she is not, then that's enough. She doesn't want a lifetime of pointless pills, prescriptions, operations. She is currently getting all this in writing and I will absolutely respect those wishes, as I hope my children will do with me.

Time and again I've seen patients or residents bed bound or without mental capacity and no quality of life already, being fed through tubes or given life prolonging drugs but for what? It's cruel IMO but I understand others may not see it that way. But sadly in my mind (maybe I'm too Clinical and have seen it too many times) I'm always thinking "how much is this all costing the NHS when this person will clearly be dead within 1-6 months anyway?

I'm not the only person who feels like either.

See I'm not clinical at all by profession but have either a capacity (or some would say incapacity) to be coldly logical about things other people get emotional about.

When my dad died of cancer earlier than he would have anyway due to a reaction to a drug trial he was put on, various family were up in arms about it and wanted to find out why he was allowed on it etc.

I was a bit "meh" - sorry he was dead as I loved him and he was my dad, but he was going to die within 12 months anyway and this way he went quickly and cost a lot less to the NHS than if he'd lingered for the 12 months.

I would probably be one of those people who could make decisions based on fact not emotion.

Even with all the undoubted complexities, it's interesting that what comes up time and again is the sheer waste and dreadful administration throughout the entire NHS (the entire public service, come to that )

If unlimited money was given, would this really improve the frontline public experience? Or would it be frittered away, as so often, on more managers to revisit priorities already known, consider how exactly the cash should be used (no doubt including a few nice jollies to "research" how others do it) and so on without end until most of it had gone?

It's not just among the public where there needs to be more responsibility/accountability, but within these byzantine organisations themselves. I don't pretend it would be easy as the resistance would be massive, but for me this is the major reform without which all others become meaningless

I worked in a hospital in a lowly admin job having previously worked as a manager in the civil service. So all public sector.
The contrast was shocking. Processes stuck in the dark ages. Rubbish IT and no expertise to run it.
Far, far too many highly paid inefficient, underworked, middle managers who are all recruited internally so no fresh ideas. This perpetuates the inward /backward looking attitudes. Managers who are poorly educated and have no management training. Managers making decisions that don't make sense to clinicians who could do a better job if they had time.

Also we need to grasp the nettle and charge for lots of services.
Hotel services, food and drink, hospital transport for attending outpatients, a small fee for GP and outpatient appointments. I could go on. No government would ever dare do this though.

Charging for food and drink in hospital? What happens to those who won't or can't pay? The truth is the standard would have to improve.

It is very complicated. Essentially, I think the NHS would spend as much money as it was given. However, in it's current state it is failing in no small part due to mismatch between resources and demand.

Increased demand is complex too, but a big factor in this is an ageing population with more complex health needs and multiple co-morbidities- in days gone by they would not have survived. Advances in treatment and medication improve survival rates, but not always huge increases in function- so can still be very frail and require a lot of medical and nurses support.

More conditions can be treated in all age groups. Medications and other treatments are becoming more advanced and are often quite expensive.

At the same time we are becoming more unhealthy as a population- rising levels of obesity, more sedentary lifestyles, binge drinking/drinking to excess and so on all contribute. For instance, a significant proportion of A&E attendances at weekends are alcohol related. Add in the increasing demand from the population more generally, including the worried well with demand for "something to be done" even about minor things/needing a review for even minor ailments or trivial things and it's all a perfect storm.

There is a mismatch between demand and the staff required to deliver the care and the staff available. There is a shortage in medical staff in most specialties now- GP/psychiatry and paediatrics (in some areas) the most pressing currently. But the gap's in medical rota's hospital wide is really quite concerning in a number of other specialties. There is also a shortage of nursing staff, midwives, psychologists and pharmacists, as well as OT/physio in some areas. Biomedical scientists to man the labs are also in short supply in some areas. The reasons for this is also complex (yes, that word again)- partly due to working conditions/issues surrounding training (nurses/midwives/junior dr's) and contractual issues with pay a contributing factor too. Brexit is not helping matters with regard to nursing recruitment. Even where the funding to recruit staff (of all professions) does exist, there are frequently simply not the staff available to take the jobs on- GP's being a prime example. This has partly been due to issues of recruitment and retainment, partly due to poor workforce planning.

Finally, there is also a mismatch between services/support and infrastructure in the community and those we require to meet demand. So often hospitals cannot discharge patents home as there is no support in the community/no step down or respite beds. And conversely, GP's quite often have to admit patents to hospital as there aren't the beds in GP-run units/respite care or support from "prevention of admission teams"/emergency carers. All this at a time where the government wants more services provided in the community. It's a complete mess!

I haven't read the whole thread but here is my two pennyworth.

I work in primary care (GP Surgery) and so many want prescriptions for Aspirin etc. which cost pennies over the counter but they will wait for over an hour to see the GP to get their prescription updated as they don't have to pay for prescriptions, what they don't realise is the true cost of have free prescriptions.

Also when you go to A&E because it is your right but then don't wait to be seen as it the wait is too long (and moan that people on stretchers are pushing in front of the queue) do you realise this is still a cost to the NHS.

People are more demanding and less likely to take responsibility for their own health preferring to have a prescription for antibiotics or referral rather than waiting to see if the cough gets better by itself (we sometimes have people come to the surgery complaining they have a sore throat and want antibiotics, when asked how long they have had the symptoms they answer 'I woke up with it this morning!!')
We are aware people are genuinely ill and not at their best but some are downright rude if we can not offer what they see as their right to an appointment today as they are desperately unwell - but then demand an appointment after school/work as they can't get to the surgery until then, or even request a home visit because they don't have the bus fare and can't afford a taxi to get to the surgery.
I don't know what the answer is for the poor old NHS but do hope somebody can come up with a workable solution - maybe charging for missed appointments which waste everybody's time from clinic clerks to consultants would be the answer but then you would have to employ more staff to chase payments
Until then please value the NHS for the wonderful all encompassing service it is and not abuse it

Charging is a can of worms, isn't it? We already charge for TV use, and there have been scandals about extortionate charges. Charging for food when the only food available costs far more than the patient would budget for were they at home? Charging for transport to outpatients when the only reason you need transport is that last year your Trust closed the local clinic? Paying to see your GP so he can tell you the routine blood test was all clear, which could be done perfectly well by the receptionist over the phone, or by you having access to your records?

We have closed cottage hospitals which could have been used to discharge people who don't need acute hospital care or are awaiting a suitable package to support them at home or placement in a nursing home etc

^
This

In the name of merging and cost cutting, smaller local hospitals have been closed and sold off to developers. This was such a big mistake as now there is no where for non acute people to go while still recovering, awaiting a care package or continuing physio etc. These smaller hospitals were a vital cog in the wheel and the powers that be were incredibly short sighted in shutting them down. What did they think that by putting everyone in one central hospital people would miraculously get better quicker and free up beds?

Definitely lack of funding in that it's increase hasn't followed the increase in need. There are many things that could be improved, but very few initiatives will make a bit of a change to the shamble the NHS is trying to cope with the aging population that is less and less looked after by their own family, putting pressure on social care and which ultimately puts pressure on the NHS. Add to that the increasing culture of poor habits by adults and growingly children and you have a bomb about to explode.

When you consider that diabetes alone causes billion of £££ and that most of it is caused by overweight/obesity, what can NHS staff do, especially when more and more pressure is being put on them, staff leaving, trusts not able to recruit.

Unfortunately, besides extra funding, any solution will have to go way beyond just revolutionising the NHS and no politician will have the ball to do it, they would never get the majority of votes anyway!

You get what you pay for and we pay relatively little as a nation for the healthcare we receive. This is why the NHS was named the most efficient in the world, yes there is waste like with all large organisations, but a lot more bang for buck than you would ever see in the US for example, which is administratively enormous.

We have very few managers actually, most people are paid a relative pittance including the professionals. Yes there are a handful of overpaid corporate bureaucrats in every hospital. Don't get me started on management consultants.

There are actually few people living to very old age (late 80s/90s) who are unwell. Most people who get to that age are genetically blessed, thin, on few or no medications. The majority with chronic illness are in their 60s/70s with ill health from bad luck/lifestyle (smoke/drink/overweight)/poverty.

They are still closing cottage hospitals. Several local cottage hospitals in my county closed last year.

I have been working in the NHS for about 18 months and am astonished at the number of people in cushy band 8+ jobs in my dept. Massively top heavy.

I've worked in the NHS for 20 years and have seen this become worse over time. Coal-face staff are getting more and more thin on the ground while supervisors and managers are ten a penny.

In my first job (in a small department) there were 5 of us on the patient-facing rota, with 1 supervisor. There was a deputy in case of sickness/holiday who got a small enhancement for this extra duty but was the same grade as all the others in the team. It worked like clockwork.

Now I'm in a bigger department. There are 9 patient-facing staff, with 4 supervisors...and there is talk of creating yet another supervisory role. There are constant squabbles between the supervisors about how to allocate the work (by the time they finish these discussions we've usually figured it out for ourselves and done it all).

It's interesting that the department continued to run without a blip when all four supervisors were off sick or on annual leave at the same time, but when two lower grade staff were off sick on the same day last week we ended up cancelling patient procedures due to lack of capable staff.

Something is very wrong somewhere.

I think it's that with all these medical advances people who need expensive treatment are surviving longer. I've had 2 premature babies and I'm extremely grateful to the NHS for saving their lives. But from a practical point of view they have both cost the NHS loads and will continue to do so. My 4 year old has had 15 operations so far and will need many more. When the NHS first began, babies like mine would have cost the NHS very little because they wouldn't have survived birth.

Actually this thread is a good place to raise a question that came to me yesterday (related to use of nhs services!)

My ds has suffered allergies and eczema rule flare ups/ hives in then past. Had terrible cradle cap as a baby.

Anyway the past few weeks he's had what looks like cradle cap on scalp and after trying anti dandruff shampoo, tea tree shampoo etc i decided to buy oilatum shampoo as ds had oilatum on prescription many years ago.

He then got really dry skin around his hairline, in his ears, over his eyebrows and on his cheeks.

So I went to pharmacy in Tesco as was doing food shop and asked for cetraban (also had before on prescription) and bought the little pump bottle for grand total of £1.91.

4 times during my conversation with her she suggested seeing Gp. Every time I asked why when I know what they'll prescribe him and have sourced that and I need to try that first. She even said that then I could get stuff on prescription.

So that's what I'm asking. Am I being incredibly thick about her reasoning why I should go and I should be trying to drive to work whilst ringing dr daily for 3 weeks whilst trying to find/ secure a gold ticketed appointment?

Or am I right in thinking it's why the nhs is struggling. Because I could have an appointment at a cost to nhs of £50 (ish) and then get prescription free at a further cost to them - instead of spending the £7 I spent to treat it with creams etc that'll last us at least a month?

I will add ds has 3 prescribed drugs already. 1 is used as needed and isn't OTC. One can be bought OTC and I buy it if I run out between his other prescription and 1 is baclofen to prescription only.
He also sees specialist neurologists, has seen general peads and pead neuro, has mri, 24 hr eeg, sleep studies, array cgh and lots of other bloods, and is waiting to see orthopaedic surgeon and likely will have surgery. He also has OT and physio!

I just think the NHS is there when we need it and he's had a lot of use when he's needed it. But there's no need for it if I can source medication OTC.